Developing a quality framework for community pharmacy: a systematic review of international literature.

OBJECTIVE: To identify the defining features of the quality of community pharmacy (CP) services and synthesise these into an evidence-based quality framework. DESIGN: Systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. DATA SOURCES: International research evidence (2005 onwards) identified from six electronic databases (Embase, PubMed, Scopus, CINAHL, Web of Science and PsycINFO) was reviewed systematically from October 2022 to January 2023. Search terms related to 'community pharmacy' and 'quality'. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Titles and abstracts were screened against inclusion or exclusion criteria, followed by full-text screening by at least two authors. Qualitative, quantitative and mixed-method studies relevant to quality in CP were included. DATA EXTRACTION AND SYNTHESIS: A narrative synthesis was undertaken. Following narrative synthesis, a patient and public involvement event was held to further refine the quality framework. RESULTS: Following the title and abstract screening of 11 493 papers, a total of 81 studies (qualitative and quantitative) were included. Of the 81 included studies, 43 investigated quality dimensions and/or factors influencing CP service quality; 21 studies assessed patient satisfaction with and/or preferences for CP, and 17 studies reported the development and assessment of quality indicators, standards and guidelines for CPs, which can help define quality.The quality framework emerging from the global literature consisted of six dimensions: person-centred care, access, environment, safety, competence and integration within local healthcare systems. Quality was defined as having timely and physical access to personalised care in a suitable environment that is safe and effective, with staff competent in the dispensing process and pharmacy professionals possessing clinical knowledge and diagnostic skills to assess and advise patients relative to pharmacists' increasingly clinical roles. CONCLUSION: The emerging framework could be used to measure and improve the quality of CP services. Further research and feasibility testing are needed to validate the framework according to the local healthcare context.

Parasitological detection of Theileria parasites in livestock in various regions of the Northern Emirates of the United Arab Emirates.

Background and Aim: Theileriosis, caused by tick-borne hemoprotozoans of the genus Theileria, severely impacts the economics of the livestock industry in most tropical and subtropical countries. The aim of the present study was to detect Theileria spp. in domesticated animals (camels, cows, sheep, and goats) using direct microscopy and to determine the infection rate in geographically distinct regions in the northern emirates of the UAE. Materials and Methods: Blood samples (n = 536) were collected from clinically symptomatic and asymptomatic domesticated animals and subjected to Giemsa staining and examined microscopically for the identification of Theileria. Results: Smears showed an overall rate of positivity for Theileria spp. in 325/536 (60.6%) animals. Different infection rates were recorded across the various animal groups in the different study areas (Middle region 215/386 [55.7%], East region 100/139 [71.9%]). Of the 11 goat samples collected from the North region, 10 (90%) were positive. Infection rates per animal group based on microscopy were as follows: camels, 3/35 (8.5%); cows, 19/36 (52.7%); goats, 200/303 (66%); and sheep, 103/162 (63.5%). Real-time polymerase chain reaction confirmation of all microscopy-positive samples identified 23/325 (7.1%) results as false-positive. Conclusion: This study clarified that Theileria spp. is present in the Middle (Sharjah, Umm Al Quwain, and Ajman), East, and North regions. This report also confirmed the use of direct microscopy with Giemsa-stained blood films as the method of choice for diagnosing acute infections. Further work is needed to molecularly determine the prevalence and species of Theileria spp. circulating in the different parts of the UAE.

Exploring the photodynamic profile of laser-generated exciplex from a conjugated polymer.

In this work, we investigated the impact of the concentration on the spectral and amplified spontaneous emission spectra (ASE) of a conducting polymer of poly(2,5-di(3,7-dimethyloctyloxy) cyanoterephthalylidene) (PDDCP) in tetrahydrofuran (THF). The findings demonstrate that the absorption spectra exhibited two peaks at 330 and 445 nm across the concentration range (1-100 µg/mL). Irrespective of the optical density, altering the concentrations did not affect the absorption spectrum. Also, the analysis indicated that the polymer did not agglomerate in the ground state for any of the concentrations mentioned. However, changes in the polymer had a substantial effect on its photoluminescence spectrum (PL), likely due to the formation of exciplexes and excimers. Also, the energy band gap also varied as a function of concentration. At a certain concentration (25 µg/mL) and pump pulse energy (3 mJ), PDDCP produced a superradiant ASE peak at 565 nm with a remarkably narrow full width at half maximum (FWHM). These findings can provide insight into the optical characteristics of PDDCP, which may have potential applications in the fabrication of tunable solid-state laser rods, Schottky diodes, and solar cell applications.

Integration of pharmacist independent prescribers into general practice: a mixed-methods study of pharmacists' and patients' views.

BACKGROUND: Since 2015, the National Health Service (NHS) has funded pharmacists to work in general practice (GP practice) to ease workload pressures. This requires pharmacists to work in new roles and be integrated effectively in GPs. Independent prescribing is a key part of the GP pharmacist role, but little is known about pharmacists' integration into GP practice as well as patients' perceptions and experiences of the care provided by GP pharmacists. This study aims to explore the perceptions of pharmacist independent prescribers (PIPs) about their integration into GP practice and gain insight into patients' perceptions about the care provided to them by pharmacists. METHODS: A mixed-methods study comprising semi-structured interviews with PIPs (n = 13) followed by questionnaire-based assessment of patients' (n = 77) evaluation of pharmacists' care was conducted between December 2019 and March 2020. Quantitative data were analysed using descriptive statistics. Interviews and open comments of the survey were thematically analysed. RESULTS: Pharmacist independent prescribers reported undertaking a range of patient-facing and non-clinical roles. Lack of understanding about PIPs' clinical role and working beyond their clinical area of competence were some of the barriers to their integration into GP practice. Most patients were satisfied with the consultations they received from pharmacists and reported confidence in the pharmacist's recommendations about their health conditions. However, a few patients (14%) felt they would still need to consult a general practitioner after their appointment and 11% were not sure if a further consultation was needed. CONCLUSIONS: Pharmacist independent prescribers provide a range of clinical services for the management of long-term conditions which appear to be recognised by patients. However, there is a need to address the barriers to PIPs' integration into GP practice to optimise their skill-mix and patient-centred care.

Using normalisation process theory to understand implementation of integrated multi-sector pre-registration trainee pharmacy technician training.

BACKGROUND: The pre-registration trainee pharmacy technician (PTPT) integrated training programme is a workforce intervention designed to train PTPTs in multiple sectors. The programme recruited 35 PTPTs to 2-year training posts which involved employment in one sector, and a minimum of 12 weeks' work-based training in ≥2 further settings each year. AIM: To identify facilitating and inhibiting factors to implementation of the PTPT integrated training programme and make recommendations on ways to embed and maintain PTPT integrated training in routine practice. METHODS: Normalisation Process Theory (NPT) constructs were used as a framework for analysis. Semi-structured interviews (14 PTPTs, 15 supervisors) explored PTPTs' learning and practice experiences over their 2-year training. A survey explored training outcomes (confidence and preparedness to practise) of integrated (n = 31) and single sector PTPTs (n = 39). RESULTS: Whilst some understood the intervention well, others had differing understandings of its purpose and potential benefits (coherence). Educational and practice supervisors acknowledged the importance of regular communication but reported difficulties implementing this due to time constraints (cognitive participation). PTPTs benefitted from having an educational supervisor oversee learning and progress over 2-years, and a practice supervisor for their day-to-day learning. PTPTs' experiences of supervision were inconsistent due to variation in supervisors' availability, knowledge, experience, and level of support (collective action). Participants perceived the PTPT integrated training as supporting development of a flexible pharmacy technician workforce able to work across sectors. The survey found that integrated PTPTs felt significantly more prepared than single-sector PTPTs to work in different settings (reflective monitoring). CONCLUSIONS: PTPTs on the programme had better ability to work in different sectors. Improving implementation requires clear understanding of the intervention's purpose by all stakeholders; clarity on supervisors' roles/contributions; and effective communication between supervisors to create effective learning opportunities. Findings can inform implementation of future multi-sector education and training globally.

Substantial Proton Ion Conduction in Methylcellulose/Pectin/Ammonium Chloride Based Solid Nanocomposite Polymer Electrolytes: Effect of ZnO Nanofiller.

In this research, nanocomposite solid polymer electrolytes (NCSPEs) comprising methylcellulose/pectin (MC/PC) blend as host polymer, ammonium chloride (NH4Cl) as an ion source, and zinc oxide nanoparticles (ZnO NPs) as nanofillers were synthesized via a solution cast methodology. Techniques such as Fourier transform infrared (FTIR), electrical impedance spectroscopy (EIS), and linear sweep voltammetry (LSV) were employed to characterize the electrolyte. FTIR confirmed that the polymers, NH4Cl salt, and ZnO nanofiller interact with one another appreciably. EIS demonstrated the feasibility of achieving a conductivity of 3.13 × 10-4 Scm-1 for the optimum electrolyte at room temperature. Using the dielectric formalism technique, the dielectric properties, energy modulus, and relaxation time of NH4Cl in MC/PC/NH4Cl and MC/PC/NH4Cl/ZnO systems were determined. The contribution of chain dynamics and ion mobility was acknowledged by the presence of a peak in the imaginary portion of the modulus study. The LSV measurement yielded 4.55 V for the comparatively highest conductivity NCSPE.

Cross-sector pre-registration trainee pharmacist placements in general practice across England: A qualitative study exploring the views of pre-registration trainees and education supervisors.

The Pharmacy Integration Fund commissioned 95 cross-sector pre-registration trainee pharmacist placements across England, which incorporated trainees spending 3-6 months in general practice (GP), whilst employed in hospital or community pharmacy. Delivery models varied (blocks or split weeks/days); trainees had pharmacist tutors at the employing/base (hospital/community pharmacy) organisation and in GP. This study aimed to evaluate implementation of cross-sector pre-registration placements, and to identify barriers and enablers of a "successful" placement that achieved its intended outcomes. A qualitative study was undertaken, using semi-structured interviews with triads/dyads of trainee and pharmacist tutors at base and/or GP site. Interviews explored trainees' and tutors' GP placement experiences, and the contribution of GP placements to achieving intended learning outcomes. Data were thematically analysed. Thirty-four interviews (14 trainees, 11 base tutors, 9 GP tutors) were completed in 11 study sites (5 GP/hospital; 6 GP/community pharmacy). GP placements were perceived as valuable and producing well-rounded pre-registration trainees with a good understanding of two settings. Key benefits of GP placements were trainees' ability to work within multidisciplinary teams, and improved clinical and consultation skills. Contingency planning/flexibility was important when setting up cross-sector placements. GP tutor supervision which supported a gradual transition from shadowing to more independent clinical practice with feedback was perceived as valuable. Good collaboration between tutors at the base and GP site ensured joined-up learning across settings. All participants considered 13 weeks in GP an appropriate minimum duration; community trainees preferred longer duration (26 weeks) for more opportunities for clinical and consultation skills learning. Base and GP tutors would welcome clarity on which pre-registration competencies should be achieved in GP placements, which would also aid quality and consistency across providers. Findings from this study identified key attributes of a successful pre-registration cross-sector training experience. These findings can inform policy reforms including changes to initial education and training of pharmacists.

Using communities of practice as a lens for exploring experiential pharmacy learning in general practice: Are communities of practice the way forward in changing the training culture in pharmacy?

BACKGROUND: Currently, there is little experiential learning in general practice (GP) during UK undergraduate and postgraduate pharmacy education and training. AIM: To apply educational theories to explore pharmacy stakeholders' perceptions of placements in general practice and contribute to the development of a model of experiential learning for pharmacy. METHODS: Qualitative, semi-structured interviews, conducted as part of two studies exploring experiential learning in general practice, with learners and their GP based supervisors. Interviews explored experiences of learning and practice, and what aided or hindered this. An abductive approach to analysis combined inductive coding with deductive, theory-driven interpretation using Lave and Wenger's concept of "Communities of Practice". RESULTS: Forty-four interviews were conducted, with learners and placement supervisors. Participants valued placements for providing authentic patient-facing learning experiences in the workplace, facilitated through legitimate peripheral participation by supervisors and supported by the use of pre- and de-briefing. Learners benefitted from support from their supervisor(s) and other staff during their day-to-day learning (informal learning), whilst also having protected time with their supervisors to discuss learning needs or go through workplace-based assessments (formal learning). Lack of clarity regarding which and how competencies should be assessed / demonstrated in general practice challenged monitoring progress from peripheral to full participation. Findings suggest that GP placements provide opportunities for learning about the patient journey between care settings; to work effectively with multidisciplinary teams; and consolidation and application of consultation / communication skills learning. CONCLUSIONS: The learning culture of GP supports learners' development, providing time and opportunities for meaningful and authentic workplace learning, with healthcare professionals acting as supervisors and mentors. These findings can usefully inform implementation of meaningful learning opportunities in primary and secondary care for those involved in pharmacy education and training.

COVID-19 and tobacco cessation: lessons from India.

OBJECTIVES: The Government of India prohibited the sale of tobacco products during the COVID-19 lockdown to prevent the spread of the SARS-CoV-2 virus. This study assessed the tobacco cessation behaviour and its predictors among adult tobacco users during the initial COVID-19 lockdown period in India. METHODS: A cross-sectional study was conducted with 801 adult tobacco users (both smoking and smokeless tobacco) in two urban metropolitan cities of India over a 2-month period (July to August 2020). The study assessed complete tobacco cessation and quit attempts during the lockdown period. Logistic and negative binomial regression models were used to study the correlates of tobacco cessation and quit attempts, respectively. RESULTS: In total, 90 (11.3%) tobacco users reported that they had quit using tobacco after the COVID-19 lockdown period. Overall, a median of two quit attempts (interquartile range 0-6) was made by tobacco users. Participants with good knowledge on the harmful effects of tobacco use and COVID-19 were significantly more likely to quit tobacco use (odds ratio [OR] 2.2; 95% confidence interval [CI] 1.2-4.0) and reported more quit attempts (incidence risk ratio 5.7; 95% CI 2.8-11.8) compared to those with poor knowledge. Participants who had access to tobacco products were less likely to quit tobacco use compared to those who had no access (OR 0.3; 95% CI 0.2-0.5]. CONCLUSIONS: Access restrictions and correct knowledge on the harmful effects of tobacco use and COVID-19 can play an important role in creating a conducive environment for tobacco cessation among users.

Enhancement of Temperature Fluorescence Brightness of Zn@Si Core-Shell Quantum Dots Produced via a Unified Strategy.

Despite many dedicated efforts, the fabrication of high-quality ZnO-incorporated Zinc@Silicon (Zn@Si) core-shell quantum dots (ZnSiQDs) with customized properties remains challenging. In this study, we report a new record for the brightness enhancement of ZnSiQDs prepared via a unified top-down and bottom-up strategy. The top-down approach was used to produce ZnSiQDs with uniform sizes and shapes, followed by the bottom-up method for their re-growth. The influence of various NH4OH contents (15 to 25 µL) on the morphology and optical characteristics of ZnSiQDs was investigated. The ZnSiQDs were obtained from the electrochemically etched porous Si (PSi) with Zn inclusion (ZnPSi), followed by the electropolishing and sonication in acetone. EFTEM micrographs of the samples prepared without and with NH4OH revealed the existence of spherical ZnSiQDs with a mean diameter of 1.22 to 7.4 nm, respectively. The emission spectra of the ZnSiQDs (excited by 365 nm) exhibited bright blue, green, orange-yellow, and red luminescence, indicating the uniform morphology related to the strong quantum confinement ZnSiQDs. In addition, the absorption and emission of the ZnSiQDs prepared with NH4OH were enhanced by 198.8% and 132.6%, respectively. The bandgap of the ZnSiQDs conditioned without and with NH4OH was approximately 3.6 and 2.3 eV, respectively.

Effect of a multicomponent intervention on achievement and improvements in quality-of-care indices among people with Type 2 diabetes in South Asia: the CARRS trial.

AIMS: To evaluate whether and what combinations of diabetes quality metrics were achieved in a multicentre trial in South Asia evaluating a multicomponent quality improvement intervention that included non-physician care coordinators to promote adherence and clinical decision-support software to enhance physician practices, in comparision with usual care. METHODS: Using data from the Centre for Cardiometabolic Risk Reduction in South Asia (CARRS) trial, we evaluated the proportions of trial participants achieving specific and combinations of five diabetes care targets (HbA1c <53 mmol/mol [7%], blood pressure <130/80 mmHg, LDL cholesterol <2.6 mmol/L, non-smoking status, and aspirin use). Additionally, we examined the proportions of participants achieving the following risk factor improvements from baseline: ≥11-mmol/mol (1%) reduction in HbA1c , ≥10-mmHg reduction in systolic blood pressure, and/or ≥0.26-mmol/l reduction in LDL cholesterol. RESULTS: Baseline characteristics were similar in the intervention and usual care arms. Overall, 12.3%, 29.4%, 36.5%, 19.5% and 2.2% of participants in the intervention group and 16.2%, 38.3%, 31.6%, 11.3% and 0.8% of participants in the usual care group achieved any one, two, three, four or five targets, respectively. We noted sizeable improvements in HbA1c , blood pressure and cholesterol, and found that participants in the intervention group were twice as likely to achieve improvements in all three indices at 12 months that were sustained over 28 months of the study [relative risk 2.1 (95% CI 1.5,2.8) and 1.8 (95% CI 1.5,2.3), respectively]. CONCLUSIONS: The intervention was associated with significantly higher achievement of and greater improvements in composite diabetes quality care goals. However, among these higher-risk participants, very small proportions achieved the complete group of targets, which suggests that achievement of multiple quality-of-care goals is challenging and that other methods may be needed in closing care gaps.

Dose-dependent thalidomide induced bradycardia in young erythema nodosum leprosum patient.

The distressing consequences of immunology in leprosy is the lepra reaction. Erythema nodosum leprosum(ENL) in special cases need to be managed with capsule thalidomide in varying doses. We report such a case of bradycardia in thalidomide dose dependent manner in a young ENL male.

Independent prescribing in primary care: A survey of patients', prescribers' and colleagues' perceptions and experiences.

Besides doctors and dentists, an increasing range of healthcare professionals, such as nurses, pharmacists and podiatrists, can become independent prescribers (IPs). As part of an evaluation for independent prescribing funded training, this study investigated views and experiences of IPs, their colleagues and patients about independent prescribing within primary care. Questionnaires capturing quantitative and qualitative data were developed for IPs, their colleagues and patients, informed by existing literature and validated instruments. IPs were identified following independent prescribing training funded by Health Education England Northwest in 2015-2017. Quantitative data were analysed using descriptive statistics and qualitative data were analysed thematically. Twenty-four patients, 20 IPs and 26 colleagues responded to the questionnaires. Most patient respondents had a long-term medical condition (n = 17) and had regular medicines prescribed (n = 21). IPs were nurses (n = 14), pharmacists (n = 4), one podiatrist (n = 1) and one was unknown. Half of the IPs were current prescribers (n = 10), the other half were still training (to become) IPs (n = 10). Colleague respondents were doctors and nurses (n = 15) other healthcare professionals (n = 8) and practice managers (n = 3). Both current IPs (n = 9) and colleague respondents (n = 25) (strongly) agreed that independent prescribing improved the quality of care provided for patients. Nearly all colleagues were supportive of independent prescribing and believed that they worked well with IPs (n = 25). Patients' perceptions and experiences of their consultations with the IP were mostly positive with the vast majority of respondents (strongly) agreeing that they were very satisfied with their visit to the IP (n = 23). Key barriers and enablers to independent prescribing were centred on IPs' knowledge, competence and organisational factors such as workload, effective teamwork and support from their colleagues. Findings from this study were mainly positive but indicate a need for policy strategies to tackle longstanding barriers to independent prescribing. However, a larger sample size is needed to confirm findings.

Community pharmacy integration within the primary care pathway for people with long-term conditions: a focus group study of patients', pharmacists' and GPs' experiences and expectations.

BACKGROUND: This study aimed to use marketing theory to examine the views of patients, pharmacists and general practitioners (GPs) on how community pharmacies are currently used and to identify how community pharmacy services may be better integrated within the primary care pathway for people with long-term conditions (LTCs). METHODS: A qualitative research design was used. Two focus groups were conducted with respiratory patients (n = 6, 5) and two with type 2 diabetes patients (both n = 5). Two focus groups were held with pharmacists (n = 7, 5) and two with GPs (both n = 5). The "7Ps marketing mix" ("product", "price", "place", "promotion", "people", "process", "physical evidence") was used to frame data collection and analysis. Data was analysed using thematic analysis. RESULTS: Due to the access and convenience of community pharmacies ("place"), all stakeholder groups recommended using community pharmacies over GP practices for services such as management of minor ailments, medication reviews and routine check-ups for well managed LTCs ("product"). All stakeholder groups preferred pharmacy services with clear specifications which focused on specific interventions to reduce variability in service delivery and quality ("process"). However, all stressed the importance of having an appropriate system to share relevant information, allowing pharmacists and GPs two-way flow ("process"). Pharmacists and GPs mentioned difficulties in collaborating with each other due to inter-professional tensions arising from funding conflicts, which leads to duplication of services and inefficient workflow within the primary care pathway ("people"). Patients and GPs were sometimes doubtful of community pharmacies' potential to expand services due to limited space, size and poor quality consultation rooms ("physical evidence"). However, all stakeholder groups recommended promoting community pharmacy services locally and nationally ("promotion"). Patients felt the most effective form of promotion was first-hand experience of high quality pharmacy services and peer word-of-mouth. The added value of using pharmacy services was faster access and convenience for patients, and freeing up GPs' time to focus on more complex patients ("value"). CONCLUSIONS: Using the 7Ps marketing mix highlighted factors which could influence utilisation and integration of community pharmacy services within the primary care pathway for patients with LTCs. Further research is needed to identify their relative importance.

Decision-making algorithm for sequential treatment of diaphyseal bone gaps in war-wounded patients in the Middle East.

INTRODUCTION: Tibial bone gaps after war injuries are common and can be managed by different types of surgery, including compression, bone graft, tibialisation of fibula, bone transport, and free flaps. Here, we present an algorithm developed at a humanitarian surgical hospital to manage tibial bone gaps. We also identify some key factors affecting patient outcomes and describe some clinical considerations for choosing treatment strategy. METHOD: We performed retrospective data analysis on war-wounded adult patients with tibial injuries treated at our project according to the described algorithm. Patient outcomes were followed for at least four  years. Outcomes assessed were length of stay, complication rate, re-admission (late complications), and final discharge. RESULTS: Among the 200 included patients, 103 (51.5%) had bone gaps. Univariate analysis showed that the presence of a bone gap, but not its size, was associated with significantly increased risk of early complications, while type of surgery was significantly correlated with re-admission. Presence of a bone gap and type of surgery were each significantly associated with length of stay. Bone gap size showed no correlation with outcomes, an unexpected finding. DISCUSSION: Soft tissue damage with compromised vascularity may explain the lack of association between bone gap size and outcomes. Specialised centres using standardised approaches to complex surgical reconstruction can play an important role in expanding the evidence base needed to improve case management. CONCLUSIONS: Less invasive procedures may lead to better patient outcomes, although unfortunately may not always be possible given the nature of the injury and/or injury site.

Solidarity or dissonance? A systematic review of pharmacist and GP views on community pharmacy services in the UK.

There has been a strong policy emphasis over the past decade on optimising patient-centred care and reducing general practitioners' (GPs') workload by extending community pharmacy services and collaboration between pharmacists and GPs. Our aim was to review current evidence of pharmacists' and GPs' views of extended community pharmacy services and pharmacists' roles in the United Kingdom (UK). A systematic review was undertaken looking at UK studies investigating pharmacists' and/or GPs' views of community pharmacy services or roles from 2005 to 2017. A range of databases were searched including EMBASE, PubMed, Scopus, Web of Science, International Pharmaceutical Abstracts (IPA), PsycINFO, Science Direct and The Cumulative Index to Nursing and Allied Health Literature (CINAHL). In addition, reference lists of included studies were screened and grey literature was searched. Following the application of inclusion/exclusion criteria, the quality of papers was critically analysed, findings were extracted into a grid and subjected to narrative synthesis following thematic analysis. The search strategy yielded a total of 4,066 unique papers from which 60 were included. Forty-seven papers covered pharmacists' views, nine combined both pharmacists' and GPs' views and four covered GPs' views. Study designs included interviews (n = 31, 52%), questionnaire surveys (n = 17, 28%) and focus groups (n = 7, 12%). Three main themes emerged from the data: "attitudes towards services/roles", "community pharmacy organisations" and "external influences". Pharmacists and GPs perceived a number of barriers to successful implementation and integration of pharmacy services. Moreover, collaboration between pharmacists and GPs remains poor despite the introduction of extended services. Overall, extending community pharmacy services require quality-driven incentives and joint working between community pharmacists and GPs to achieve better integration within the patient's primary care pathway.

Acceptability of a decision-support electronic health record system and its impact on diabetes care goals in South Asia: a mixed-methods evaluation of the CARRS trial.

AIMS: To describe physicians' acceptance of decision-support electronic health record system and its impact on diabetes care goals among people with Type 2 diabetes. METHODS: We analysed data from participants in the Centre for Cardiometabolic Risk Reduction in South Asia (CARRS) trial, who received the study intervention (care coordinators and use of a decision-support electronic health record system; n=575) using generalized estimating equations to estimate the association between acceptance/rejection of decision-support system prompts and outcomes (mean changes in HbA1c , blood pressure and LDL cholesterol) considering repeated measures across all time points available. We conducted in-depth interviews with physicians to understand the benefits, challenges and value of the decision-support electronic health record system and analysed physicians' interviews using Rogers' diffusion of innovation theory. RESULTS: At end-of-trial, participants with diabetes for whom glycaemic, systolic blood pressure, diastolic blood pressure and LDL cholesterol decision-support electronic health record prompts were accepted vs rejected, experienced no reduction in HbA1c [mean difference: -0.05 mmol/mol (95% CI -0.22, 0.13); P=0.599], but statistically significant improvements were observed for systolic blood pressure [mean difference: -11.6 mmHg (95% CI -13.9, -9.3); P ≤ 0.001], diastolic blood pressure [mean difference: -5.2 mmHg (95% CI -6.5, -3.8); P ≤ 0.001] and LDL cholesterol [mean difference: -0.7 mmol/l (95% CI -0.6, -0.8); P ≤0.001], respectively. The relative advantages and compatibility of the decision-support electronic health record system with existing clinic set-ups influenced physicians' acceptance of it. Software complexities and data entry challenges could be overcome by task-sharing. CONCLUSION: Wider adherence to decision-support electronic health record prompts could potentially improve diabetes goal achievement, particularly when accompanied by assistance from a non-physician health worker.

Uterine exteriorization versus intraperitoneal repair: effect on intraoperative nausea and vomiting during repeat cesarean delivery - A randomized clinical trial.

OBJECTIVE: The current study aims to compare the rate of intraoperative nausea and vomiting after repeat cesarean delivery (CD) under two different approaches: by intraperitoneal incision repair or by uterus exteriorization for incision reapair. MATERIALS AND METHODS: We conducted a single-blinded randomized clinical trial (NCT03009994) at a tertiary University Hospital between the 1st of September 2016 and the 31st of December 2017. The study included pregnant women at term of gestation (>37 weeks) scheduled for repeat CD under spinal anesthesia. Women were assigned to either uterine exteriorization for incision repair (Group I) or intraperitoneal incision repair (Group II). The primary assessed was the rate of nausea and vomiting during CD. RESULTS: The study included 1028 women in the final analysis. The rate of intraoperative nausea and vomiting was significantly lower in the intraperitoneal repair group compared to the exteriorization group (24% versus 38.7%, p= 0.001). Likewise, occurrence of uterine atony and the need for additional uterotonics were significantly lower in the intraperitoneal repair group (p= 0.001 and 0.02 respectively). Postoperatively, the rate of nausea and vomiting (12.6 % versus 21 %; P=0.001), and the time to the first recognized bowel movement (12.3 hours versus 14.1 hours; P=0.003) were significantly lower in the intraperitoneal repair group compared to the exteriorization group. CONCLUSIONS: Intraperitoneal repair of the uterine incision during repeat CD is beneficial compared to exteriorization. Improvements in the rate of intra- and postoperative nausea, vomiting, uterine atony and time to the first recognized bowel movement were observed in patients operated with this technique.